Merck Manual

Please confirm that you are a health care professional

honeypot link

Educating Patients on Effective Poison Treatments—Commentary

Commentary
10/14/16 Gerald F. O’Malley, DO, Grand Strand Regional Medical Center|Sidney Kimmel School of Medicine, Thomas Jefferson University Hospital;

The medical community’s understanding and treatment of poisoning has evolved significantly in the last several decades. For example, decades ago, clinicians used a so-called universal antidote to counteract poisonous substances; today, clinicians have de-emphasized universal antidotes as well as gastric emptying.

In the 1950s and 1960s, treatment for many poisoning cases focused on the universal antidote—a combination of activated charcoal, magnesium oxide, and tannic acid. But after research in the 1960s suggested adding magnesium and tannic acid actually interfered with the effects of the activated charcoal, toxicology experts began suggesting patients and doctors use only charcoal to treat poisonings. Today, there is no role for the universal antidote.

Additionally, many commonly used at-home treatments such as syrup of ipecac and other methods of inducing vomiting like inserting fingers into the throat are no longer recommended for poison victims, for example, because they risk aspiration and, if an ingestion involves a caustic substance, can also cause serious esophageal, throat, and oral injuries that could worsen the initial poisoning.

Today, poison victims may be surprised to learn that detection techniques like testing urine and, particularly, blood, are not often helpful, especially if the patient isn’t sure what substance is to blame. Even if the patient does have a guess at the source of the poison, there are only about 40 specific antidotes used in clinical medicine, and hospitals usually only stock a fraction of them, which have been selected based on recommendations from an expert panel issued in 2009. Identification of specific poisons is often low-tech, creative work, such as using all possible sources (friends, family, witnesses, etc.) to obtain history of what was ingested and physical examination to identify specific toxidromes. Also identification of specific poisons is often unnecessary because treatment of poisoning relies largely on observation and supportive care. And most poisonings involve multiple substances.

Although details regarding diagnosis and treatment are often unnecessary for patients, many aspects of poisonings, particularly about prevention and first aid, are helpful for them to know. When you discuss these topics with your patients, make sure that they have a current, accurate understanding of them.

Poison Control Center—a valuable resource

In a majority of cases, the crucial moments immediately following discovering a potential poisoning incident are best spent calling the American Association of Poison Control Centers (AAPCC) and traveling to the closest emergency department if that’s what poison control center experts advise. However, more than 70 percent of calls to poison control centers are managed on-site, meaning that the caller got the help they needed over the phone and didn't have to go to a hospital or a health care provider, according to the AAPCC.

Individuals should make full use of the resources provided by the 56 poison control centers in the U.S. and understand that they can call the hotline for expert guidance regarding any concern, including possible pet poisonings (as many as 2 percent of all calls to the hotline involve pet poisonings). Physicians and other medical professionals rely on the centers as well -- nearly a quarter (21 percent) of calls to poison control centers came from health care facilities.

The poison control center website also has a pill identifier resource, where individuals can search for medications based on imprint code, shape/color and name. The website also includes information on specific substances as well as hazards more likely to affect different age groups during different times of the year. Users can also access real-time poison assistance directly from the website and find download links to the webPOISONCONTROL app.

Be aware of single pills that can kill

The human body has evolved effective ways of removing toxins. But a single dose of some medications is enough to be potentially fatal, especially for children. Parents, especially new parents, should be made aware of these medications and the symptoms they’re likely to generate in children who ingest them. For example, if a child takes a single dose of certain diabetes medications, the child may slip into a diabetic coma while parents believe he or she is sleeping. The LSU School of Medicine published a review for physicians on medications and herbal remedies that could kill a child with a single dose.

While this advice has been around for a long time, it’s still valuable: Store all medication in childproof containers high off the ground and locked away if necessary to keep children and others from being able to get to them.

Topical medications present a danger

Oil of wintergreen, even used topically, can cause severe salicylate toxicity. Patients may also underestimate the potential severity of poisonings that come from medicinal patches or other topical sources. Often, a significant amount of medication remains on a patch even after the patient has worn it for the recommended duration of treatment. Parents may have a hard time finding the patch if a child picks it up, puts it on or ingests it, leading to dangerous absorption risks. Make sure parents understand that medicinal patches, especially those used for pain, should be disposed of safely so that children cannot get to them.

An ongoing poison threat – carbon monoxide

While instances where an individual or child has swallowed a potentially toxic substance may demand immediate attention and treatment, there are other forms of poisoning in which the exposure occurs over time that also present serious dangers.

Carbon monoxide poisoning is especially dangerous because its symptoms are nonspecific, especially with low levels of carbon monoxide exposure. Symptoms at various exposure levels include:

  • Headache and nausea can begin when levels are 10 to 20%.
  • Levels > 20% commonly cause vague dizziness, generalized weakness, difficulty concentrating, and impaired judgment.
  • Levels > 30% commonly cause dyspnea during exertion, chest pain (in patients with coronary artery disease), and confusion.
  • Higher levels can cause syncope, seizures, and obtundation.

For physicians who have seen the severe effects of carbon monoxide poisonings on families, the situation is made that much more frustrating by the fact that carbon monoxide detectors are an easy, affordable method of prevention for individuals and their families.

Physicians can refer patients to the consumer version of the Merck Manuals to give them a more accurate understanding of the dangers of poisoning and how to respond if they or a family member suspects a poisoning incident occurred.